Policy win

Anthem steps back from plans to cut E&M payment by 50%

E&M services billed with Modifier 25 were scheduled for decrease under planned policy.


In the wake of strong objections from physician organizations including AOA, Anthem health insurance provider announced it has abandoned plans to reduce payments for evaluation and management (E&M) services that are reported with modifier 25.

All contracted providers will be notified of the reversal, the company said. In late 2017, Anthem announced it would reduce E&M payments by 25 percent when modifier 25 was used. Originally, the insurer had planned to cut those payments by 50 percent.

“We are pleased to see Anthem has rightfully shifted away from an arbitrary cut in physician payment that ultimately would have made it far more difficult for patients to access care,” said Mat Kremke, AOIA vice president.

“Health plans need to work with physician groups including AOA to create policies that result in high-quality care at a reasonable cost. E&M services are integral to providing appropriate, cost-effective care that delivers good outcomes for patients.”

Anthem has faced sharp criticism for policies that retrospectively denied payment for emergency room visits. While the company has revised some of those policies, patients and physician groups noted that the company’s decisions are based on the diagnosis, rather than the symptoms that prompted patients to seek emergency care.

One comment

  1. Scott Leone, DO

    Would you please report on what the AOA is doing with re: to another large national payer, -Aetna- who also denies E/M services or lowers payments for them significantly when the -25 modifier is appended?
    Patients who have their annual health maintenance exam, but have acute needs deserve to have them addressed without requiring a separate return visit, and physician’s addressing those needs on the same day deserve to be paid for the added service.

Leave a comment Please see our comment policy